What is the treatment for suboxone (buprenorphine) withdrawal?

Treatment for Suboxone (Buprenorphine) Withdrawal

For patients discontinuing Suboxone, a slow taper using divided doses of buprenorphine combined with symptomatic management is the recommended approach, though evidence suggests shorter tapers (7 days) may be as effective as longer tapers (28 days) for preventing relapse. 1, 2

Tapering Strategies

Standard Taper Approach

• Gradual dose reduction is the primary method for managing buprenorphine withdrawal, though the optimal taper duration remains debated 2
• A 7-day taper produces comparable or better outcomes than a 28-day taper, with 44% of patients providing opioid-free urine samples at the end of a 7-day taper versus only 30% with a 28-day taper 2
• However, both taper durations show similar poor outcomes at 1-month (18% opioid-free) and 3-month (12-13% opioid-free) follow-up, suggesting that taper duration alone does not prevent relapse 2

Novel Approach: Extended-Release Buprenorphine

• A single 100 mg injection of extended-release buprenorphine can facilitate complete discontinuation from low-dose sublingual buprenorphine by providing a gradual decline in buprenorphine levels that mitigates prolonged withdrawal symptoms 3
• This approach has shown success in patients who previously failed traditional tapering methods due to intolerable withdrawal symptoms including nausea, malaise, anxiety, and dysphoria 3

Symptomatic Management

Alpha-2 Agonists

• Clonidine or lofexidine can be used as adjunctive therapy to manage autonomic withdrawal symptoms, though they are less effective than buprenorphine itself for opioid withdrawal 1
• These medications address symptoms such as sweating, tachycardia, hypertension, and anxiety 1

Assessment Tools

• Use the Clinical Opiate Withdrawal Scale (COWS) to objectively assess withdrawal severity and guide treatment decisions 1
• Mild withdrawal (COWS <8) may not require pharmacological intervention beyond symptomatic support 1

Critical Considerations When Restarting Buprenorphine

Risk of Precipitated Withdrawal

• If a patient needs to restart buprenorphine after using full opioid agonists during or after taper, they must be in mild to moderate opioid withdrawal before buprenorphine administration to avoid precipitated withdrawal 1
• Buprenorphine's high receptor affinity can displace full agonists and cause severe precipitated withdrawal if administered too early 4
• Wait at least 12 hours after short-acting opioids (heroin, morphine IR), 24 hours after extended-release formulations, or 72 hours after methadone before restarting buprenorphine 1

Managing Precipitated Withdrawal

• If precipitated withdrawal occurs despite appropriate timing, administer high-dose buprenorphine rapidly (up to 20 mg total) rather than the traditional 2 mg every 1-2 hours 4
• This aggressive approach is safe and allows rapid reversal of withdrawal symptoms, particularly important given the rising prevalence of fentanyl-contaminated drugs 4

Important Caveats

Drug Interactions During Withdrawal

• CYP3A4 inducers (rifampin, carbamazepine, phenytoin) can decrease buprenorphine plasma concentrations and precipitate withdrawal symptoms 5
• Conversely, stopping CYP3A4 inhibitors (macrolides, azole antifungals, protease inhibitors) during taper can also trigger withdrawal 5
• Monitor for these interactions and adjust taper schedule accordingly 5

Harm Reduction Measures

• Provide naloxone kits for overdose prevention, as patients discontinuing buprenorphine face increased overdose risk if they return to illicit opioid use 1
• Offer hepatitis C and HIV screening during the withdrawal process 1
• Ensure access to behavioral health support and counseling, as medication alone has poor long-term outcomes 1, 6

Reconsider Discontinuation

• Given the poor long-term outcomes after buprenorphine discontinuation (only 12-13% opioid-free at 3 months), strongly consider whether discontinuation is truly in the patient's best interest 2
• Long-term maintenance therapy with buprenorphine is associated with reduced mortality and improved quality of life compared to discontinuation 1, 6